Alliance for Patient Safety

                            All that is necessary for the triumph of evil...
                                                                ... is for good men to do nothing.

                                                                                                   Edmund Burke

Lumetra report recommends our " Black Box " concept.


Excerpts from "Comprehensive Study of Peer Review in California" - July, 31, 2008 - A report by Lumetra to the Medical Board of California

Read Full Report at the Medical Board of California Website:


Page 108, " Recommendations "

1. Re-design the peer review process and create an independent review organization

Page 109,

" Refer any physician whose actions related to patient care do not meet the standard of care of the screening, or " fall out " of the screens for any reason, to an UNBIASED INDEPENDENT PEER REVIEW ORGANIZATION that has no vested interest in the review outcome except protection of the public.

The independent organization will be selected by the MBC or the appropriate legislative committee. All further responsibility for making decisions about taking any action toward the physician, including 805 or 821.5 reporting would be removed from the healthcare entity.

After the initial identification by the healthcare entity, the independent organization would take over all further investigation of the issue and make a recommendation to the healthcare entity regarding either filing an 805 report or other action,... A copy of all recommendations would be sent to the MBC. The healthcare entity would decide to follow or not follow the recommendation.

If a healthcare entity has an event (serious event or sentinel event) that requires an expedited or " fast track " review, that event would be reported to the independent entity within five hours. the independent organization would expedite the review/investigation (no longer than three days) and make an action recommendation to the MBC and to the healthcare entity (805, summary suspension if not already imposed, or other action)."

Page 110, 3. Revise role of the MBC

" The responsibility of the 809 (Peer Review) Hearing would be removed from healthcare entities. The MBC or a designated independent organization would conduct 809 hearings to insure fairness.

Through the MBC, oversight for investigations, 809 hearings, and probation monitoring would be under the auspices of a " professional jury " composed of all practicing physicians. This " jury " service would be for a set of time period and rotated among all licensed physicians in the State, being sure to only use people who did not have prior direct contact with the parties of the issue. "